Infection prevention and control (PDF) - NICE

Infection prevention and control

Quality standard

Published: 17 April 2014 www.nice.org.uk/guidance/qs61

© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-rights).

https://www.nice.org.uk/guidance/qs61

Contents Contents Introduction ........................................................................................................................................................................ 5

Why this quality standard is needed ....................................................................................................................................... 5

How this quality standard supports delivery of outcome frameworks ..................................................................... 6

Coordinated services ..................................................................................................................................................................... 7

List of quality statements ............................................................................................................................................... 9

Quality statement 1: Antimicrobial stewardship ................................................................................................. 10

Quality statement ........................................................................................................................................................................... 10

Rationale ............................................................................................................................................................................................ 10

Quality measures ............................................................................................................................................................................ 10

What the quality statement means for different audiences .......................................................................................... 11

Source guidance ............................................................................................................................................................................... 11

Definitions of terms used in this quality statement .......................................................................................................... 12

Quality statement 2: Organisational responsibility ........................................................................................... 14


Rationale ............................................................................................................................................................................................ 14



Source guidance ............................................................................................................................................................................... 16


Quality statement 3: Hand decontamination ....................................................................................................... 17


Rationale ............................................................................................................................................................................................ 17



Source guidance ............................................................................................................................................................................... 18


Quality statement 4: Urinary catheters .................................................................................................................. 20

Infection prevention and control (QS61)


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Rationale ............................................................................................................................................................................................ 20



Source guidance ............................................................................................................................................................................... 22


Quality statement 5: Vascular access devices ...................................................................................................... 25


Rationale ............................................................................................................................................................................................ 25



Source guidance ............................................................................................................................................................................... 26


Quality statement 6: Educating people about infection prevention and control .................................... 29


Rationale ............................................................................................................................................................................................ 29



Source guidance ............................................................................................................................................................................... 31


Equality and diversity considerations ..................................................................................................................................... 32

Using the quality standard ............................................................................................................................................. 33


Levels of achievement ................................................................................................................................................................... 33

Using other national guidance and policy documents ...................................................................................................... 33

Diversity, equality and language ................................................................................................................................. 34

Development sources ...................................................................................................................................................... 35

Evidence sources ............................................................................................................................................................................. 35



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Policy context .................................................................................................................................................................................. 35

Definitions and data sources for the quality measures .................................................................................................. 36

Related NICE quality standards .................................................................................................................................. 37

Quality Standards Advisory Committee and NICE project team ................................................................. 38

Quality Standards Advisory Committee ................................................................................................................................ 38

NICE project team .......................................................................................................................................................................... 40

Update information .......................................................................................................................................................... 41

About this quality standard ........................................................................................................................................... 42



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This standard is based on CG69, CG139 and PH36.

This standard should be read in conjunction with QS49, QS14, QS15, QS72, QS90, QS63,

QS66, QS89, QS110, QS113, QS121, QS141, QS161 and QS168.

Introduction Introduction This quality standard covers the prevention and control of infection for people receiving healthcare

in primary, community and secondary care settings.

Settings include hospitals, general practices, dental clinics, health centres, care homes, the person's

own home, schools and prisons providing healthcare, and care delivered by the ambulance service

and mental health services.

For more information see the topic overview.

Why this quality standard is needed Why this quality standard is needed

Healthcare-associated infections can develop either as a direct result of healthcare intervention

(such as medical or surgical treatment) or from being in contact with a healthcare setting

(Healthcare associated infections [Public Health England]).

Healthcare-associated infections arise across a wide range of clinical conditions and can affect

people of all ages. They can exacerbate existing or underlying conditions, delay recovery and

adversely affect quality of life. Healthcare-associated infections can occur in otherwise healthy

people, especially if invasive procedures or devices are used. Healthcare workers, family members

and carers are also at risk of acquiring infections when caring for people. A number of factors can

increase the risk of acquiring an infection, but high standards of infection prevention and control

practice, including providing clean environments, can minimise the risk.

NHS England's 2011 survey on healthcare-associated infections and antimicrobial use estimated

that 300,000 patients a year in England acquire a healthcare-associated infection as a result of care

within the NHS. The prevalence of healthcare-associated infections in hospitals in England in 2011

was 6.4%. The most common types of healthcare-associated infection are respiratory infections

(including pneumonia and infections of the lower respiratory tract; 22.8%), urinary tract infections

(17.2%) and surgical site infections (15.7%). Each one of these infections means additional use of



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http://www.nice.org.uk/guidance/qs61/documents

https://www.gov.uk/government/collections/healthcare-associated-infections-hcai-guidance-data-and-analysis

https://webarchive.nationalarchives.gov.uk/20140714085429/http:/www.hpa.org.uk/Publications/InfectiousDiseases/AntimicrobialAndHealthcareAssociatedInfections/1205HCAIEnglishPPSforhcaiandamu2011prelim/

NHS resources, greater patient discomfort and a decrease in patient safety.

In 2007, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridium

difficile infections were recorded as the underlying cause of, or a contributory factor in,

approximately 9,000 deaths in hospital and primary care in England. Since 2006 there has been an

18-fold reduction in MRSA bloodstream infections (from 1.3% to less than 0.1%) and a 5-fold

reduction in Clostridium difficile infections (from 2% to 0.4%) (NHS England's 2011 survey on

healthcare-associated infections and antimicrobial use).

It is important that this quality standard is implemented alongside other national guidance, current

policy documents and regulatory standards listed in the policy context section.

This quality standard has been developed as part of a group of topics on infection prevention and

control across a range of settings. The infection prevention and control quality standard is an

overarching quality standard; other quality standards and guidance have been published (for

example, NICE's quality standard on surgical site infection), are in development and have been

referred to NICE that provide topic-specific detail on aspects of infection prevention and control.

The quality standard is expected to contribute to improvements in the following outcomes:

• infection rates

• avoidable deaths from healthcare-associated infections.

How this quality standard supports delivery of outcome How this quality standard supports delivery of outcome frameworks frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable

quality improvements within a particular area of health or care. They are derived from high-quality

guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in

conjunction with the guidance on which it is based, should contribute to the improvements outlined

in the following outcomes framework published by the Department of Health:

• NHS Outcomes Framework 2014 to 2015

Table 1 shows the outcomes, overarching indicators and improvement areas from the frameworks

that the quality standard could contribute to achieving.



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https://www.gov.uk/government/publications/nhs-outcomes-framework-2014-to-2015

Table 1 NHS Outcomes Framework 2014 to 2015 Table 1 NHS Outcomes Framework 2014 to 2015

Domain Domain Overarching indicators and improvement Overarching indicators and improvement

areas areas

1 Preventing people from dying prematurely

Overarching indicator Overarching indicator

1a Potential Years of Life Lost (PYLL) from

causes considered amenable to healthcare

1ai Adults

1aii Children and young people

4 Ensuring that people have a positive

experience of care

Overarching indicator Overarching indicator

4a Patient experience of primary care i GP

services

4b Patient experience of hospital care

5 Treating and caring for people in a safe

environment and protect them from avoidable

harm

Improvement areas Improvement areas

Reducing the incidence of avoidable harm Reducing the incidence of avoidable harm

5.2 Incidence of healthcare associated

infection (HCAI)

5.2i MRSA

5.2ii C. difficile

Coordinated services Coordinated services

The quality standard for infection prevention and control specifies that services should be

commissioned from and coordinated across all relevant agencies. A person-centred, integrated

approach that promotes multi-agency working is fundamental to delivering high-quality care and

preventing and controlling infection.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should

consider NICE quality standards in planning and delivering services, as part of a general duty to

secure continuous improvement in quality. Commissioners and providers of health and social care

should refer to the library of NICE quality standards when designing high-quality services. Other

quality standards that should also be considered when choosing, commissioning or providing a

high-quality infection prevention and control service are listed in related quality standards.



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Training and competencies Training and competencies

The quality standard should be read in the context of national and local guidelines on training and

competencies. All healthcare workers and social care and public health practitioners involved in

infection prevention and control should have sufficient and appropriate training and competencies

to deliver the actions and interventions described in the quality standard.

Role of families and carers Role of families and carers

Quality standards recognise the important role families and carers have in infection prevention and

control. If appropriate, healthcare workers and social care and public health practitioners should

ensure that family members and carers are involved in the decision-making process about

investigations, treatment and care.



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List of quality statements List of quality statements Statement 1 People are prescribed antibiotics in accordance with local antibiotic formularies as

part of antimicrobial stewardship.

Statement 2 Organisations that provide healthcare have a strategy for continuous improvement in

infection prevention and control, including accountable leadership, multi-agency working and the

use of surveillance systems.

Statement 3 People receive healthcare from healthcare workers who decontaminate their hands

immediately before and after every episode of direct contact or care.

Statement 4 People who need a urinary catheter have their risk of infection minimised by the

completion of specified procedures necessary for the safe insertion and maintenance of the

catheter and its removal as soon as it is no longer needed.

Statement 5 People who need a vascular access device have their risk of infection minimised by the

completion of specified procedures necessary for the safe insertion and maintenance of the device

and its removal as soon as it is no longer needed.

Statement 6 People with a urinary catheter, vascular access device or enteral feeding tube, and

their family members or carers (as appropriate), are educated about the safe management of the

device or equipment, including techniques to prevent infection.



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Quality statement 1: Antimicrobial stewardship Quality statement 1: Antimicrobial stewardship

Quality statement Quality statement

People are prescribed antibiotics in accordance with local antibiotic formularies as part of

antimicrobial stewardship.

Rationale Rationale

Antibiotic resistance poses a significant threat to public health, particularly because antibiotics

underpin routine medical practice in both primary and secondary care. To help prevent the

development of current and future bacterial resistance, it is important to prescribe antibiotics

according to the principles of antimicrobial stewardship, such as prescribing antibiotics only when

they are needed (and not for self-limiting mild infections such as colds and most coughs, sinusitis,

earache and sore throats) and reviewing the continued need for them. These principles should be

set out within local antibiotic guidelines and pathways and be consistent with the local antibiotic

formulary. Local antibiotic formularies should indicate a range of antibiotics for managing common

infections, and permit use of other antibiotics only on the advice of the microbiologist or physician

responsible for the control of infectious diseases.

Quality measures Quality measures

Structure Structure

a) Evidence of local antibiotic formularies governing the use of antibiotics to ensure that people are

prescribed antibiotics appropriately.

Data source:Data source: Local data collection.

b) Evidence that local antibiotic formularies are reviewed regularly.


c) Evidence of local audits of the appropriateness of antibiotic prescribing.




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Outcome Outcome

Antibiotic prescribing rates (primary and secondary care).

Data source for primary care:Data source for primary care: National prescribing comparator data available from the NHS Digital

Information Services Portal, specifically the number of prescription items for antibacterial drugs

per Specific Therapeutic Group Age-sex weightings Related Prescribing Unit (STAR-PU), and the

number of prescription items for cephalosporins and quinolones as a percentage of the total

number of prescription items for selected antibacterial drugs (British National Formulary [BNF]).

Data source for secondary care:Data source for secondary care: Local data collection.

What the quality statement means for different What the quality statement means for different audiences audiences

Service providersService providers ensure that they have antimicrobial stewardship initiatives in place, including

local antibiotic formularies for antibiotic prescribing.

Healthcare professionals Healthcare professionals ensure that when they prescribe antibiotics they do so in accordance with

local antibiotic formularies as part of antimicrobial stewardship.

CommissionersCommissioners ensure that they commission services that have antimicrobial stewardship

initiatives and in which people are prescribed antibiotics in accordance with local antibiotic

formularies.

PeoplePeople are offered antibiotics according to local guidance about which ones are most suitable. This

includes not being offered antibiotics if they don't need them (for example, if they have a cold, a

sore throat, most coughs or earache). This is to try to reduce the problem of antibiotic resistance,

which is when an infection no longer responds to treatment with one or more types of antibiotic

and so is more likely to spread and can become serious.

Source guidance Source guidance

• Antimicrobial stewardship: changing risk-related behaviours in the general population. NICE

guideline NG63 (2017), recommendations 1.5.1 and 1.5.3

• Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use.

NICE guideline NG15 (2015), recommendations 1.1.32 and 1.1.33



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https://applications.nhsbsa.nhs.uk/infosystems/welcome


https://bnf.nice.org.uk/treatment-summary/antibacterials-principles-of-therapy.html

https://www.nice.org.uk/guidance/ng63




• Expert consensus

Definitions of terms used in this quality statement Definitions of terms used in this quality statement

Local antibiotic formulary Local antibiotic formulary

A local antibiotic formulary is a local policy document produced by a multi-professional team,

usually in a hospital trust or commissioning group, combining best evidence and clinical judgement.

[NICE's full guideline on surgical site infections, glossary]

A local antibiotic formulary is defined as 'the output of processes to support the managed

introduction, utilisation or withdrawal of healthcare treatments within a health economy, service

or organisation. [NICE's guideline on developing and updating local formularies]

Local policies often limit the antibiotics that may be used to achieve reasonable economy

consistent with adequate cover, and to reduce the development of resistant organisms. A policy

may indicate a range of antibiotics for general use, and permit other antibiotics only on the advice

of the medical microbiologist or physician responsible for the control of infectious diseases. [BNF

Antibacterials, principles of therapy]

Antimicrobial stewardship Antimicrobial stewardship

Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting

and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness.

[Adapted from the Department of Health Advisory Committee on Antimicrobial Resistance and

Healthcare Associated Infection (ARHAI)'s antimicrobial prescribing and stewardship

competencies]

The approach to prescribing in line with the principles of antimicrobial stewardship recommended

for secondary care is as follows:

• Do not start antibiotics without clinical evidence of bacterial infection.

• If there is evidence or suspicion of bacterial infection, use local guidelines to start prompt,

effective antibiotic treatment.

• Document the following on the medicines chart and in the person's medical notes: clinical

indication, duration or review date, route and dose.



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http://www.nice.org.uk/guidance/NG125/evidence

https://www.nice.org.uk/guidance/mpg1



https://www.gov.uk/government/publications/antimicrobial-prescribing-and-stewardship-competencies



• Obtain cultures – knowing the susceptibility of an infecting organism can lead to narrowing of

broad-spectrum therapy, changing therapy to effectively treat resistant pathogens, and

stopping antibiotics when cultures suggest an infection is unlikely.

• Prescribe single-dose antibiotics for surgical prophylaxis if antibiotics have been shown to be

effective.

• Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from the first

antibiotic dose and make a clear plan of action – the 'Antimicrobial Prescribing Decision'. The 5

Antimicrobial Prescribing Decision options are: Stop, Switch Intravenous to Oral, Change,

Continue, and Outpatient Parenteral Antibiotic Therapy (OPAT).

• Clearly document the review and subsequent decision in the person's medical notes.

[ARHAI's guidance on antimicrobial stewardship: Start smart – then focus]

The approach to prescribing in line with the principles of antimicrobial stewardship recommended

for primary care is as follows:

• Prescribe an antibiotic only if there is likely to be a clear clinical benefit.

• Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract

infections.

• Limit prescribing over the phone to exceptional cases.

• Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (for example, co-

amoxiclav, quinolones and cephalosporins) if narrow-spectrum antibiotics remain effective,

because the former increase the risk of Clostridium difficile, methicillin-resistant Staphylococcus

aureus (MRSA) and antibiotic-resistant urinary tract infections.

• Avoid widespread use of topical antibiotics (especially those that are also available as systemic

preparations, such as fusidic acid).

[Adapted from Public Health England's managing common infections: guidance for primary care]



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https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus

https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care

Quality statement 2: Organisational Quality statement 2: Organisational responsibility responsibility


Organisations that provide healthcare have a strategy for continuous improvement in infection

prevention and control, including accountable leadership, multi-agency working and the use of

surveillance systems.

Rationale Rationale

It is essential that organisations and agencies work together to coordinate strategies for infection

prevention and control across a local area. It is equally important to share information across

organisations in order to meet responsibilities for establishing the current position on infection

control, monitoring the impact of quality improvement initiatives and ongoing surveillance.

Leadership underpins all infection prevention and control, and is vital to ensure that this remains a

priority for the organisation as a whole and each person working within it.


Structure Structure

a) Evidence that the organisation includes infection prevention and control within its overall

strategy.


b) Evidence that the organisation's board is up to date with, and has a working knowledge and

understanding of, infection prevention and control.


c) Evidence that a lead for infection prevention and control has been assigned and is taking an

active role.




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d) Evidence of support for, and participation in, joint working initiatives beyond mandatory or

contractual requirements, to reduce healthcare-associated infections locally.


e) Evidence of an adequately resourced surveillance system with specific, locally defined objectives

and priorities for preventing and managing healthcare-associated infections.


Outcome Outcome

Incidence of healthcare-associated infection.

Data source:Data source:2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcomes

Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus

(MRSA) and Clostridium difficile. Data are derived from Public Health England's mandatory

reporting of healthcare-associated infections (also reported by the NHS Digital's National Indicator

Library).


Service providersService providers ensure that a strategy is in place for continuous improvement in infection

prevention and control that includes accountable leadership, multi-agency working and

surveillance systems.

Healthcare professionalsHealthcare professionals ensure that they implement strategies for continuous improvement in

infection prevention and control through accountable leadership, multi-agency working and

adhering to the requirements of surveillance systems.

CommissionersCommissioners ensure that they commission services from organisations that have strategies for

continuous improvement in infection prevention and control that include accountable leadership,

multi-agency working and surveillance systems.

PeoplePeople receive healthcare from organisations that aim to continually improve their approach to

preventing infection (for example, by sharing information with other organisations and monitoring

rates of infection).



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https://digital.nhs.uk/data-and-information/publications/clinical-indicators/ccg-outcomes-indicator-set


https://hcaidcs.phe.org.uk/webpages/GeneralHomePage.aspx?AspxAutoDetectCookieSupport=1


https://digital.nhs.uk/data-and-information/national-indicator-library



Healthcare-associated infections: prevention and control. NICE guideline PH36 (2011), quality

improvement statements 1, 3 and 6


Board Board

A board is defined as a group of members with overall responsibility and accountability for the

governance, safety and quality of an organisation. [Expert opinion]



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https://www.nice.org.uk/guidance/ph36

Quality statement 3: Hand decontamination Quality statement 3: Hand decontamination


People receive healthcare from healthcare workers who decontaminate their hands immediately

before and after every episode of direct contact or care.

Rationale Rationale

Effective hand decontamination, even after wearing gloves, results in significant reductions in the

carriage of potential pathogens on the hands and decreases the incidence of preventable

healthcare-associated infections, leading in turn to a reduction in morbidity and mortality. Hand

decontamination is considered to have a high impact on outcomes that are important to patients.

Although hand hygiene has improved over recent years, remaining misconceptions about this

standard principle of infection control are reported and good practice is still not universal.


Structure Structure

a) Evidence of local arrangements to ensure the availability of facilities for hand decontamination.


b) Evidence of local arrangements to ensure that all healthcare workers receive training in hand

decontamination.


c) Evidence of local arrangements to ensure that regular local hand hygiene observation audits are

undertaken.


Outcome Outcome

Incidence of healthcare-associated infection.



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Data source:Data source:2014/15 NHS Outcomes Framework indicator 5.2.


Service providersService providers ensure that healthcare workers are trained in effective hand decontamination

techniques, and that handrub and handwashing facilities are available so that healthcare workers

can decontaminate their hands immediately before and after every episode of direct contact or

care.

Healthcare workers Healthcare workers ensure that they are trained in effective hand decontamination techniques,

and that they decontaminate their hands immediately before and after every episode of direct

contact or care, even when gloves have been worn.

CommissionersCommissioners ensure that they commission services in which healthcare workers are trained in

effective hand decontamination techniques and decontaminate their hands immediately before

and after every episode of direct contact or care, and that hand hygiene observation audits are

carried out regularly.

People receiving healthcarePeople receiving healthcare are looked after by healthcare workers who always clean their hands

thoroughly (using handrub or soap and water), both immediately before and immediately after

coming into contact with the person or carrying out care.


• Healthcare-associated infections: prevention and control in primary and community care.

NICE guideline CG139 (2012, updated 2017), recommendation 1.1.2.1 (key priority for

implementation)

• Loveday HP, Wilson JA, Pratt RJ et al. epic3: National evidence-based guidelines for preventing

healthcare-associated infections in NHS hospitals in England (2014), recommendation SP6


Hand decontamination Hand decontamination

Hand decontamination is the use of handrub or handwashing to reduce the number of bacteria on

the hands. The term is often interchangeable with 'hand hygiene'.



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https://www.nice.org.uk/guidance/cg139


http://www.journalofhospitalinfection.com/article/S0195-6701(13)60012-2/fulltext


An alcohol-based handrub should be used for hand decontamination before and after direct

contact or care, except in the following situations when soap and water must be used:

• when hands are visibly soiled or potentially contaminated with body fluids or or

• when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not

gloves have been worn.

[Adapted from NICE's guideline on healthcare-associated infections, recommendation 1.1.2.2, and

epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS

hospitals in England, recommendation SP7]

Direct contact or care Direct contact or care

Direct contact or care refers to 'hands on' or face-to-face contact with patients. This encompasses

any physical aspect of the healthcare of a patient, including treatments, self-care and

administration of medication. [NICE's guideline on healthcare-associated infections]



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Quality statement 4: Urinary catheters Quality statement 4: Urinary catheters


People who need a urinary catheter have their risk of infection minimised by the completion of

specified procedures necessary for the safe insertion and maintenance of the catheter and its

removal as soon as it is no longer needed.

Rationale Rationale

Catheter-associated urinary tract infections comprise a large proportion of healthcare-associated

infections, and can occur whether a person has either a short-term or a long-term catheter. There is

a strong association between duration of urinary catheterisation and risk of infection, and

catheters are sometimes inserted inappropriately or there is a delay in removing them. This risk is

greatly reduced by complying with all parts of the process for safe catheter insertion, maintenance

and removal as soon as it is no longer needed. This is important in terms of both infection

prevention and patient comfort and experience.


Structure Structure

Evidence of a written protocol to ensure that people who need a urinary catheter have their risk of

infection minimised by the completion of specified procedures necessary for the safe insertion and

maintenance of the catheter and its removal as soon as it is no longer needed.


Process Process

a) Proportion of people with a short-term urinary catheter who had their risk of infection

minimised by the completion of specified procedures necessary for the safe insertion and

maintenance of the catheter and its removal as soon as it is no longer needed.

Numerator – the number of people in the denominator for whom all of the specified procedures

were completed for the safe insertion and maintenance of the catheter and its removal as soon as it

is no longer needed.



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Denominator – the number of people who have had a short-term urinary catheter.


b) Proportion of people with a long-term urinary catheter who had their risk of infection minimised

by the completion of specified procedures necessary for the safe insertion and maintenance of the

catheter and its removal as soon as it is no longer needed.


were completed for the safe insertion and maintenance of the catheter and its removal as soon as it

is no longer needed were completed.

Denominator – the number of people who have had a long-term urinary catheter.


Outcome Outcome

a) Incidence of healthcare-associated infection.





Library).

b) Incidence of catheter-associated urinary tract infection.

Data source:Data source: Local data collection. NHS safety thermometer.


Service providersService providers ensure that systems and facilities are in place to enable staff to complete

specified procedures necessary for the safe insertion and maintenance of the catheter and its

removal as soon as it is no longer needed, in order to minimise the risk of infection.

Healthcare workers Healthcare workers ensure that they complete specified procedures necessary for the safe



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https://www.safetythermometer.nhs.uk/

insertion and maintenance of the catheter and its removal as soon as it is no longer needed, in order

to minimise the risk of infection.

CommissionersCommissioners ensure that they commission services in which specified procedures necessary for

the safe insertion and maintenance of the catheter and its removal as soon as it is no longer needed

are completed, in order to minimise the risk of infection.

People who need a urinary catheterPeople who need a urinary catheter have their risk of infection minimised by healthcare workers

carrying out procedures to make sure that the catheter is inserted, looked after and removed

correctly and safely. These procedures include things like cleaning hands, using a lubricant when

inserting the catheter, emptying the drainage bag when necessary, and removing the catheter as

soon as it is no longer needed. A urinary catheter is a thin flexible tube used to drain urine from the

bladder.



NICE guideline CG139 (2012, updated 2017), recommendations 1.2.2.1 to 1.2.2.3, 1.2.4.3,

1.2.4.4, 1.2.5.1 to 1.2.5.3, 1.2.5.5, 1.2.5.6, 1.2.5.8 and 1.2.5.9


healthcare-associated infections in NHS hospitals in England, (2014) recommendations

UC1–UC3, UC8–UC11, UC13–UC17 and UC19


Urinary catheter Urinary catheter

A urinary catheter is a catheter that is inserted in the urethra and remains in place until it is no

longer needed. Both short-term (used for 28 days or less) and long-term (used for more than

28 days) urinary catheters are used. [Adapted from NICE's full guideline on healthcare-associated

infections and epic3: National evidence-based guidelines for preventing healthcare-associated

infections in NHS hospitals in England]



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http://www.nice.org.uk/guidance/cg139/evidence




Specified procedures necessary for the safe insertion, Specified procedures necessary for the safe insertion, maintenance and appropriate removal of urinary catheters maintenance and appropriate removal of urinary catheters

Assessing the need for catheterisation Assessing the need for catheterisation

• Catheterisation should be used only after considering alternative methods of management.

The person's clinical need for catheterisation should be reviewed regularly and the urinary

catheter removed as soon as possible. The need for catheterisation, as well as details about

insertion, changes and care should be documented.

Hand hygiene Hand hygiene

• Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile

gloves before manipulating a person's catheter, and must decontaminate their hands after

removing gloves.

Catheter insertion Catheter insertion

• The meatus should be cleaned before the catheter is inserted, in accordance with local

guidelines or policy (for example, with sterile normal saline).

• An appropriate lubricant from a single-use container should be used during catheter insertion

to minimise urethral trauma and infection.

Catheter maintenance Catheter maintenance

• Indwelling catheters should be connected to a sterile closed urinary drainage system or

catheter valve. Healthcare workers should ensure that the connection between the catheter

and the urinary drainage system is not broken, except for good clinical reasons (for example,

changing the bag in line with the manufacturer's recommendations).

• Urinary drainage bags should be positioned below the level of the bladder, and should not be in

contact with the floor. The urinary drainage bag should be emptied frequently enough to

maintain urine flow and prevent reflux, and should be changed when clinically indicated. A

separate and clean container should be used for each person. Contact between the urinary

drainage tap and container should be avoided.

• Urine samples must be obtained from a sampling port using an aseptic technique.

• The meatus should be washed daily with soap and water as part of routine daily personal

hygiene.



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[Adapted from NICE's guideline on healthcare-associated infections and epic3: National evidence-

based guidelines for preventing healthcare-associated infections in NHS hospitals in England]



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Quality statement 5: Vascular access devices Quality statement 5: Vascular access devices


People who need a vascular access device have their risk of infection minimised by the completion

of specified procedures necessary for the safe insertion and maintenance of the device and its

removal as soon as it is no longer needed.

Rationale Rationale

Vascular access devices are one of the main causes of healthcare-associated infections, and

bloodstream infections associated with central venous device insertion are a major cause of

morbidity. The risk of infection is greatly reduced by complying with all parts of the process for safe

insertion and maintenance of the device and its removal as soon as it is no longer needed.


Structure Structure

Evidence of a written protocol to ensure that people who need a vascular access device have their

risk of infection minimised by the completion of specified procedures necessary for the safe

insertion and maintenance of the device and its removal as soon as it is no longer needed.


Process Process

Proportion of people with a vascular access device who had their risk of infection minimised by the

completion of specified procedures necessary for the safe insertion and maintenance of the device

and its removal as soon as it is no longer needed.


were completed for the safe insertion and maintenance of the device and its removal as soon as it is

no longer needed.

Denominator – the number of people who have had a vascular access device.



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Data source:Data source: Local data collection. Contained in the UK Renal Registry Annual Report.

Outcome Outcome

Incidence of vascular access device-related bloodstream infection.

Data source:Data source:Local data collection.


Service providersService providers ensure that systems and facilities are in place to enable staff to complete

specified procedures necessary for the safe insertion and maintenance of the vascular access

device and its removal as soon as it is no longer needed, in order to minimise risk of infection.

Healthcare workersHealthcare workers ensure that they complete specified procedures necessary for the safe

insertion and maintenance of the vascular access device and its removal as soon as it is no longer

needed, in order to minimise the risk of infection.

CommissionersCommissioners ensure that they commission services in which specified procedures necessary for

the safe insertion and maintenance of the vascular access device and its removal as soon as it is no

longer needed are completed, in order to minimise the risk of infection.

People who needPeople who needa vascular access device a vascular access device have their risk of infection minimised by healthcare

workers carrying out procedures to make sure that the device is inserted, looked after and

removed correctly and safely. These procedures include things like using sterile procedures when

inserting the device, using the correct antiseptics and dressings, and removing the device as soon as

it is no longer needed. A vascular access device is a tube that is inserted into a main vein or artery

and used to administer fluids and medication, monitor blood pressure and collect blood samples.



NICE guideline CG139 (2012, updated 2017), recommendations 1.4.2.1, 1.4.2.2, 1.4.3.1 (key

priority for implementation), 1.4.3.2, 1.4.4.1, 1.4.4.6, 1.4.4.12 to 1.4.4.14



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https://www.renalreg.org/publications-reports




healthcare-associated infections in NHS hospitals in England (2014), recommendations IVAD4

to IVAD5, IVAD13 to IVAD15, IVAD17, IVAD23 to IVAD24, IVAD30, IVAD34, IVAD37 to

IVAD39


Vascular access device Vascular access device

A vascular access device is an indwelling catheter, cannula or other instrument used to obtain

venous or arterial access. Both central and peripheral vascular access devices are available.

Specified procedures necessary for the safe insertion, Specified procedures necessary for the safe insertion, maintenance and appropriate removal of vascular access devices maintenance and appropriate removal of vascular access devices

General asepsis General asepsis

• Healthcare workers must decontaminate their hands before accessing or dressing a vascular

access device, using an alcohol handrub or by washing with liquid soap and water if hands are

contaminated. An aseptic technique must be used for vascular access device catheter site care,

when accessing the system and when administrating intravenous medication.

Skin decontamination Skin decontamination

• The skin should be decontaminated at the insertion site with 2% chlorhexidine gluconate in

70% alcohol and allowed to dry before inserting a vascular access device.

Vascular access device site care Vascular access device site care

• A sterile transparent semipermeable membrane dressing should be used to cover the vascular

access device insertion site. This should be changed every 7 days, or sooner if it is no longer

intact or if moisture collects under the dressing.

• A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone

iodine) should be used and allowed to dry when cleaning the insertion site during dressing

changes.



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Vascular access device management Vascular access device management

• A single-use application of 2% chlorhexidine gluconate in 70% alcohol (or aqueous povidone

iodine) should be used to decontaminate the access port or catheter hub. The hub should be

cleaned for 15 seconds and allowed to dry before accessing the system.

• Preferably, a sterile 0.9% sodium chloride injection should be used to flush and lock catheter

lumens.

• Administration sets for blood and blood components should be changed when the transfusion

episode is complete or every 12 hours (whichever is sooner), or according to the

manufacturer's recommendations. Administration sets used for total parenteral nutrition

infusions should generally be changed every 24 hours. If the solution contains only glucose and

amino acids, administration sets in continuous use do not need to be replaced more frequently

than every 72 hours.

Review of vascular access devices Review of vascular access devices

• Peripheral vascular catheter insertion sites should be inspected during every shift at a

minimum, and a visual phlebitis score should be recorded.

• Central venous catheter insertion sites should be inspected daily.

[Adapted from NICE's guideline on healthcare-associated infections and epic3: National evidence-

based guidelines for preventing healthcare-associated infections in NHS hospitals in England]



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Quality statement 6: Educating people about Quality statement 6: Educating people about infection prevention and control infection prevention and control


People with a urinary catheter, vascular access device or enteral feeding tube, and their family

members or carers (as appropriate), are educated about the safe management of the device or

equipment, including techniques to prevent infection.

Rationale Rationale

Because many people with a urinary catheter, vascular access device or enteral feeding tube

manage their own device or equipment, it is important that they and their family members or carers

are confident about, and proficient in, infection prevention and control practices and the safe

management of the device or equipment.


Structure Structure

Evidence of local arrangements for people with a urinary catheter, vascular access device or enteral

feeding tube, and their family members or carers (as appropriate), to be educated about the safe

management of their device or equipment, including techniques to prevent infection.


Process Process

Proportion of people with a urinary catheter, vascular access device or enteral feeding tube, and

their family members or carers (as appropriate), who are educated about the safe management of

their device or equipment, including techniques to prevent infection.

Numerator – the number of people in the denominator who are educated about the safe

management of their device or equipment, including techniques to prevent infection.

Denominator – the number of people with a urinary catheter, vascular access device or enteral



Page 29 of43

feeding tube, and their family members or carers (as appropriate).


Outcome Outcome

a) Incidence of healthcare-associated infection.





Library).

b) People with a urinary catheter, vascular access device or enteral feeding tube, and their family

members or carers (as appropriate), feel able to manage their device or equipment.

Data source:Data source: Local data collection using a patient survey to demonstrate that patients and carers

have understood their education.


Service providersService providers ensure that there are systems in place for people with a urinary catheter,

vascular access device or enteral feeding tube, and their family members or carers (as appropriate),

to be educated about the safe management of the device or equipment, including techniques to

prevent infection.

Healthcare workers Healthcare workers ensure that they educate people with a urinary catheter, vascular access

device or enteral feeding tube, and their family members or carers (as appropriate), about the safe

management of the device or equipment, including techniques to prevent infection.

CommissionersCommissioners ensure that they commission services in which people with a urinary catheter,

vascular access device or enteral feeding tube, and their family members or carers (as appropriate),

are educated about the safe management of the device or equipment, including techniques to

prevent infection.

People who have a urinary catheter, a vascular access device or an enteral feeding tube, and any People who have a urinary catheter, a vascular access device or an enteral feeding tube, and any



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family members or carers who help them with this equipment, family members or carers who help them with this equipment, are given information and advice

about how to look after the equipment safely and effectively. This includes advice about how to

prevent infection. Enteral feeding is a type of feeding used for people who cannot eat normally in

which liquid food is given through a tube directly into the gut.



NICE guideline CG139 (2012, updated 2017), recommendations 1.2.1.1, 1.3.1.1 and 1.4.1.1

(key priority for implementation)


healthcare-associated infections in NHS hospitals in England (2014), recommendations UC22

and IVAD3


Urinary catheter Urinary catheter

A urinary catheter is a catheter that is inserted in the urethra and remains in place until it is no

longer needed. Both short-term (used for 28 days or less) and long-term (used for more than

28 days) urinary catheters are used. [Adapted from NICE's full guideline on healthcare-associated

infections and epic3: National evidence-based guidelines for preventing healthcare-associated

infections in NHS hospitals in England]

Vascular access device Vascular access device

A vascular access device is an indwelling catheter, cannula or other instrument used to obtain

venous or arterial access. Both central and peripheral vascular access devices are available.

Enteral feeding Enteral feeding

Enteral feeding is feeding via a tube that can include any method of providing nutrition via the

gastrointestinal tract. [NICE's full guideline on healthcare-associated infections]

Education about infection prevention and control Education about infection prevention and control

Education for people and their carers about infection prevention and control should always cover

the techniques of hand decontamination. In addition, education should be provided as follows:



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For people with a urinary catheter, education should cover insertion of intermittent catheters

where applicable, how to manage the catheter and drainage system, how to minimise the risk of

urinary tract infections and how to obtain additional supplies suitable for individual needs. [NICE's

guideline on healthcare-associated infections, recommendation 1.2.1.1, and epic3: National

evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in

England, recommendation UC22]

For people with a vascular access device, education should cover any technique needed to prevent

infection and safely manage the device. [NICE's guideline on healthcare-associated infections,

recommendation 1.4.1.1, and epic3: National evidence-based guidelines for preventing healthcare-

associated infections in NHS hospitals in England, recommendation IVAD3]

For people needing enteral feeding, education should cover techniques of feeding and management

of the administration system. [NICE's guideline on healthcare-associated infections,

recommendation 1.3.1.1]

Equality and diversity considerations Equality and diversity considerations

People with a cognitive impairment or a lack of mobility may need additional support to undertake

hand decontamination and other techniques to prevent infection. Language barriers should not be

a reason for not providing advice.

If religious beliefs are a source of concern in relation to the use of alcohol hand rubs for hand

decontamination, people could be made aware of the official views of religious bodies about the

products. If information is available, people should be directed to these sources.



Page 32 of43










Using the quality standard Using the quality standard


The quality measures accompanying the quality statements aim to improve the structure, process

and outcomes of care in areas identified as needing quality improvement. They are not a new set of

targets or mandatory indicators for performance management.

See NICE's how to use quality standards for further information, including advice on using quality

measures.

Levels of achievement Levels of achievement

Expected levels of achievement for quality measures are not specified. Quality standards are

intended to drive up the quality of care, and so achievement levels of 100% should be aspired to (or

0% if the quality statement states that something should not be done). However, NICE recognises

that this may not always be appropriate in practice, taking account of safety, choice and

professional judgement, and therefore desired levels of achievement should be defined locally.

Using other national guidance and policy documents Using other national guidance and policy documents

Other national guidance and current policy documents have been referenced during the

development of this quality standard. It is important that the quality standard is considered

alongside the documents listed in development sources.



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https://www.nice.org.uk/standards-and-indicators/how-to-use-quality-standards

Diversity, equality and language Diversity, equality and language During the development of this quality standard, equality issues have been considered and equality

assessments for this quality standard are available.

Good communication between healthcare workers and social care and public health practitioners is

essential. Treatment, care and support, and the information given about it, should be culturally

appropriate. It should also be accessible to people with additional needs such as physical, sensory

or learning disabilities, and to people who do not speak or read English. People receiving healthcare

should have access to an interpreter or advocate if needed.

Commissioners and providers should aim to achieve the quality standard in their local context, in

light of their duties to have due regard to the need to eliminate unlawful discrimination, advance

equality of opportunity and foster good relations. Nothing in this quality standard should be

interpreted in a way that would be inconsistent with compliance with those duties.



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http://www.nice.org.uk/guidance/QS61/Documents

http://www.nice.org.uk/guidance/QS61/Documents

Development sources Development sources Further explanation of the methodology used can be found in the quality standards process guide

on the NICE website.

Evidence sources Evidence sources

The documents below contain recommendations from NICE guidance or other NICE-accredited

recommendations that were used by the Quality Standards Advisory Committee to develop the

quality standard statements and measures.


healthcare-associated infections in NHS hospitals in England. (2014) Journal of Hospital

Infection 86 (supplement 1): S1–70


NICE guideline CG139 (2012, updated 2017)

• Healthcare-associated infections: prevention and control. NICE guideline PH36 (2011)

Policy context Policy context

It is important that the quality standard is considered alongside current policy documents,

including:

• Department of Health. UK 5 year antimicrobial resistance strategy 2013 to 2018 (2013)

• Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare

Associated Infection (ARHAI). Antimicrobial stewardship: Start smart – then focus (2011)

• Care Quality Commission. Essential standards of quality and safety (2010)

• Department of Health. High impact intervention: central venous catheter care bundle (2010)

• Department of Health. High impact intervention: urinary catheter care bundle (2010)

• Department of Health. The Health and Social Care Act 2008: code of practice on the

prevention and control of infections and related guidance (2010)



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https://www.nice.org.uk/standards-and-indicators/timeline-developing-quality-standards





https://www.nice.org.uk/guidance/ph36

https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018



https://www.cqc.org.uk/

http://webarchive.nationalarchives.gov.uk/20120118164404/http:/hcai.dh.gov.uk/whatdoido/high-impact-interventions/

http://webarchive.nationalarchives.gov.uk/20120118164404/http:/hcai.dh.gov.uk/whatdoido/high-impact-interventions/

https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance

https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance

• National Audit Office. Reducing healthcare associated infections in hospitals in England (2009)

Definitions and data sources for the quality measures Definitions and data sources for the quality measures

• British National Formulary. Antibacterials, principles of therapy

• Developing and updating local formularies. NICE guideline MPG1 (2014)

• Department of Health. 2014/15 NHS Outcomes Framework

• Department of Health. 2014/15 Clinical Commissioning Group (CCG) Outcomes Indicator Set

• NHS safety thermometer

• NHS Information Services Portal

• Public Health England. Managing common infections guidance for primary care (2013)

• Public Health England and Department of Health Expert Advisory Committee on

Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Antimicrobial

prescribing and stewardship competencies (2013)

• Department of Health Advisory Committee on ARHAI. Antimicrobial stewardship: Start smart

– then focus (2011)



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http://www.nao.org.uk/report/reducing-healthcare-associated-infections-in-hospitals-in-england/


https://www.nice.org.uk/guidance/mpg1


https://digital.nhs.uk/data-and-information/publications/statistical/ccg-outcomes-indicator-set

https://www.safetythermometer.nhs.uk/


https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care






Related NICE quality standards Related NICE quality standards This quality standard has been developed in the context of all quality standards developed by NICE.

• Surgical site infection. NICE quality standard 49 (2013)

• Patient experience in adult NHS services. NICE quality standard 15 (2012, updated 2019)

• Service user experience in adult mental health. NICE quality standard 14 (2011, updated

2019)



Page 37 of43




Quality Standards Advisory Committee and NICE Quality Standards Advisory Committee and NICE project team project team

Quality Standards Advisory Committee Quality Standards Advisory Committee

This quality standard has been developed by Quality Standards Advisory Committee 3.

Membership of this committee is as follows:

Dr Hugh McIntyre (Chair) Dr Hugh McIntyre (Chair)

Consultant physician, East Sussex Healthcare Trust

Mrs Alison Raw (Acting Chair at prioritisation meeting) Mrs Alison Raw (Acting Chair at prioritisation meeting)

Head of integrated health and care, Lewisham

Dr Jim Stephenson (Vice Chair) Dr Jim Stephenson (Vice Chair)

Consultant medical microbiologist, Epsom and St Helier NHS Trust

Dr Alastair Bradley Dr Alastair Bradley

General medical practitioner, Tramways Medical Centre/Academic Unit of Primary Medical Care,

University of Sheffield

Ms Jan Dawson Ms Jan Dawson

Public health nutrition lead and registered dietician, Manchester City Council

Dr Matthew Fay Dr Matthew Fay

General practitioner, Westcliffe Medical Practice, Shipley, West Yorkshire

Dr Malcolm Fisk Dr Malcolm Fisk

Co-director, Ageing Society Grand Challenge Initiative, Coventry University

Mrs Margaret Goose Mrs Margaret Goose

Lay member

Mrs Geeta Kumar Mrs Geeta Kumar

Clinical director, Women's Services (East), Betsi Cadwaladr University Health Board



Page 38 of43

Mrs Rhian Last Mrs Rhian Last

Clinical lead, Education for Health

Mrs Mandy Nagra Mrs Mandy Nagra

CDF/ IFR manager specialised commissioning, NHS England

Ms Ann Nevinson Ms Ann Nevinson

Lay member

Dr Jane O'Grady Dr Jane O'Grady

Director of public health, Buckinghamshire County Council

Mrs Jane Orr-Campbell Mrs Jane Orr-Campbell

Director, Orr-Campbell Consultancy

Professor Gillian Parker Professor Gillian Parker

Professor of social policy research and director, Social Policy Research Unit, University of York

Mr David Pugh Mr David Pugh

Independent consultant (MCA), Gloucestershire County Council

Dr Eve Scott Dr Eve Scott

Head of safety and risk, Christie NHS Foundation Trust

Mr Darryl Thompson Mr Darryl Thompson

Psychosocial interventions development lead, South West Yorkshire Partnership NHS Foundation

Trust

Mrs Julia Thompson Mrs Julia Thompson

Strategic commissioning manager, Sheffield City Council

The following specialist members joined the committee to develop this quality standard:

Dr Robert Carr Dr Robert Carr

Consultant in communicable disease control, Public Health England

Dr Peter Jenks Dr Peter Jenks

Director of infection prevention and control, Plymouth Hospitals NHS Trust



Page 39 of43

Mr Gavin Maxwell Mr Gavin Maxwell

Lay member

Dr Carol Pellowe Dr Carol Pellowe

Senior lecturer, King's College London

Mrs Sue Wright Mrs Sue Wright

Infection prevention and control lead, Peninsula Community Health, Cornwall

NICE project team NICE project team

Dylan Jones Dylan Jones

Associate director

Shirley Crawshaw Shirley Crawshaw

Consultant clinical adviser

Rachel Neary-Jones Rachel Neary-Jones

Programme manager

Terence Lacey Terence Lacey

Technical adviser

Anna Brett Anna Brett

Lead technical analyst (until December 2013)

Nicola Greenway Nicola Greenway

Lead technical analyst (from December 2013)

Esther Clifford Esther Clifford

Project manager

Lee Berry Lee Berry

Coordinator



Page 40 of43

Update information Update information Minor changes since publication Minor changes since publication

September 2021: September 2021: The source guidance for statement 1 was updated because it was replaced by

recommendations in the NICE guidelines on antimicrobial stewardship: changing risk-related

behaviours in the general population and antimicrobial stewardship: systems and processes for

effective antimicrobial medicine use.

April 2019: April 2019: References and source guidance sections have been updated throughout to align this

quality standard with updated NICE guidance.

December 2016:December 2016: Data source updated for statement 5.



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About this quality standard About this quality standard NICE quality standards describe high-priority areas for quality improvement in a defined care or

service area. Each standard consists of a prioritised set of specific, concise and measurable

statements. NICE quality standards draw on existing NICE or NICE-accredited guidance that

provides an underpinning, comprehensive set of recommendations, and are designed to support

the measurement of improvement.

The methods and processes for developing NICE quality standards are described in the quality

standards process guide.

This quality standard has been incorporated into the NICE Pathways on prevention and control of

healthcare-associated infections and antimicrobial stewardship.

NICE produces guidance, standards and information on commissioning and providing high-quality

healthcare, social care, and public health services. We have agreements to provide certain NICE

services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other

products apply in those countries are made by ministers in the Welsh government, Scottish

government, and Northern Ireland Executive. NICE guidance or other products may include

references to organisations or people responsible for commissioning or providing care that may be

relevant only to England.

ISBN: 978-1-4731-0540-9

Endorsing organisation Endorsing organisation This quality standard has been endorsed by NHS England, as required by the Health and Social

Care Act (2012)

Supporting organisations Supporting organisations Many organisations share NICE's commitment to quality improvement using evidence-based

guidance. The following supporting organisations have recognised the benefit of the quality

standard in improving care for patients, carers, service users and members of the public. They have

agreed to work with NICE to ensure that those commissioning or providing services are made



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http://pathways.nice.org.uk/pathways/prevention-and-control-of-healthcare-associated-infections

http://pathways.nice.org.uk/pathways/prevention-and-control-of-healthcare-associated-infections

https://pathways.nice.org.uk/pathways/antimicrobial-stewardship

aware of and encouraged to use the quality standard.

• Independent Healthcare Advisory Services • MRSA Action UK • Royal College of Anaesthetists • Royal College of General Practitioners (RCGP) • Royal College of Nursing (RCN) • Royal College of Pathologists • Royal College of Physicians (RCP) • Royal Pharmaceutical Society • UK Clinical Pharmacy Association (UKCPA) • Association of Physicians’ Assistants (Anaesthesia) • Association for Safe Aseptic Practice • Healthcare Infection Society • Infection Prevention Society • St John Ambulance • Faculty of General Dental Practice



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http://www.independenthealthcare.org.uk/

http://mrsaactionuk.net/

http://www.rcoa.ac.uk/

https://www.rcgp.org.uk/

http://www.rcn.org.uk/

http://www.rcpath.org/

http://www.rcplondon.ac.uk/

http://www.rpharms.com/home/home.asp

http://ukclinicalpharmacy.org/

http://anaesthesiateam.com/

http://antt.org/antt_site/the-asap.html

http://www.his.org.uk/

http://www.ips.uk.net/

http://www.sja.org.uk/sja/default.aspx

http://www.fgdp.org.uk/